Eugene Shotsman (3:24)

So do you think the gap is in the, in the chair? Do you think the gap is just like general parent awareness of this, or do you think the gap is the pushback that optometrists get when they do talk about it?

Matt Erding (3:39)

I think it's multifaceted. It starts with parent awareness. So even though there's been some work in the last few years to drive more parents to be aware, work from the Global Myopia Awareness Coalition, GMAC CooperVision's been investing in my site. We at Treehouse Eyes have done some investments in parent marketing. Overall awareness is still really low. It takes a long time, as you know, to build awareness of a new treatment and a new category. So we're still in the early stages of that. So what that means is it's up to the optometrist or their staff to bring it up. And that can be an uncomfortable conversation for an optometrist, especially maybe if they've been seeing that kid for a few years, they've been getting glasses or contact lenses, and suddenly you're bringing up something new that is a treatment for myopia rather than just correcting their myopia. So a lot of optometrists have struggled with case presentation. How do I talk about this? Right. How does my staff maybe bring it up in the right way so that we're teeing up the parent to have a meaningful conversation? Because if you put it on the optometrist to talk about this in the chair, especially in locations that maybe only have a 15 or 20 minute exam time. We know optometrists are time starved. It can be a challenging conversation and it may take a few minutes. In fact, even if you know what you're doing and you're using the right words, you're talking to the parent in the right way, it may still be a 10 or 15 minute conversation with that parent to educate them and help them understand why you're recommending treatment for their child. So there's a lot of work to do on both ends, both on the parent awareness building, but also arming optometrists and their staff with the right tools and training to help them bring this up in the right way.

Eugene Shotsman (5:26)

Yeah, it's interesting. And by the way, that 4 to 5%, is that shifting in the right direction or is that like stagnant for years and years?

Matt Erding (5:36)

It's shifting in the right direction. Five years ago, which is the first time we saw measurements of it. When I was on the board of GMAC, it was down around 2%. So we're definitely seeing an improvement in that, but just not fast enough. We really got to grow this category faster because we know we're missing a generation of kids if we don't catch them early. It's not like presbyopia where if I don't treat you when you're 48 and first have the symptoms, well, I can treat you four years later and give you a pair of progressives or multifocal contact lenses. If we miss the kid when they're 8, 9, 10, 11, 12, and maybe we initiated treatment about discussion when they're 14, we've missed an opportunity to help that child have better vision for life, but also reduce that axial length as well.

Eugene Shotsman (6:24)

Yeah, so I think we're going to get into a conversation about parent psychology because I know you guys do a lot of research on that. I think we're going to talk a lot about some of the new things on the market for treating myopia and also people who are investing in parent education and maybe we'll even get into like some of the techniques that you guys teach that work. But before that, I do think it's probably valid for the audience to have a little bit of context as to like where you're coming from. If they're not familiar with Treehouse. And part of the origin story for you has to do with like your personal story. So I think it might be really interesting for people. Just give us a quick 2 minute background on so that people Understand the context with which you're able to provide some of this advice and some of this data that you're about to share.

Matt Erding (7:16)

Yeah, my origin story goes back much earlier than most might expect. It goes to 2007. I was running the global franchise at Sibavision and we had a partnership with Brian Holden Vision Institute in Australia, where we were licensing designs for soft contact lenses to slow the progression of myopia in children. And when I took over that role, I'd been in eye care for several years. At that point, I had no idea that this was even something we could do. I was blown away that there was a possibility that we could slow down that progression of childhood myopia. So I got to know Brian Holden back then and that was the first time it really planted the seed in me of this is meaningful. Like this goes beyond just vision correction. This is actually a medical treatment. Unfortunately, that project never really showed the efficacy that we wanted there. So I went on with my career. Siva vision became Alcon. And I got a call from Dr. Gary Gerber about 10 years ago and he said, what are you guys doing about myopia at ALCON at this point in time? And it wound up turning this long discussion and Gary's perspective of it's not going to be about the products, products are available already 10 years ago. That could slow down the progression of childhood myopia. The challenge was going to be how do we get adoption of this, how do we get optometrists to embrace this, how do we help them, knowing it's probably going to be a private pay procedure to get comfortable recommending it when the parent's going to be unaware. So we decided to start treehouse eyes about 10 years ago. And the defining moment for me was September 1, 2015. So I remember the date because when it was my birthday. But we're sitting in a research focus group facility in New Jersey and we have a moderator in the room. And we had 16 parents of myoptic children coming in for one on one interviews and we're sitting behind the glass door or the glass window where they can't see us. And what we were trying to understand is if parents knew that there was a way to help their child not become a minus 6, minus 8, minus 9, and they would have to pay for that. It would involve, at that point in time, really all we knew about was custom contact lens options, orthokay or soft lenses, would they be interested? That was really what the research was designed to do, is would they be interested? Would they be willing to invest. And what types of words would we need to use to talk to them about this? Because remember, 10 years ago, nobody really knew about this, certainly in the public. And that research really convinced me that if you know how to talk to parents in the right way, and I'm a parent myself, every parent wants this for their child. Every parent wants to help their kids health. And that really is what convinced me to leave Alcon, start treehouse eyes with Dr. Gerber. And then to your point, my. My own personal story. So we had started Treehouse Eyes, I think we'd been going about four years, and my youngest daughter was eight years old. And we were. I coached her soccer team. After the soccer game, it was always a tradition to go to McDonald's. So we're at McDonald's, we're waiting to order. And I looked at her and she's squinting. And I looked at her, I said, why are you squinting? She goes, the menu's a little blurry because the menu's behind the register. And I just. My heart sick. And I'm like, oh, no, she's got my wife's eyes. My wife's a minus six and I'm an EmMetro. So took her to the OD. We went anyway every year to the optometrist for a comprehensive eye exam. And sure enough, she was already minus 75 and a year before she'd been plus 50. So she had a huge shift in that period of time. Got her on treatment. Fast forward. She was on treatment for about four years. And instead of becoming a minus six, which is what our calculators projected she would be, she's been stable for three years at a minus 175. So her axial length is less than 24. And so we've helped her, you know, we've, we've given her vision that's going to last her lifetime. Her risk of retinal disease, et cetera, is dramatically reduced because we were able to intervene. So it's, it's also personal for me.

Eugene Shotsman (11:39)

Yeah, that's really cool. And I, and I like how your story started with, you know, parent research in some capacity. Right before you did the, before you started the business, you tried to evaluate do parents want this service? Obviously what you found motivated you to start the business. But talk a little bit more about the kind of research you guys have done with parents and what you found that you're willing to share that is that, I guess, helps make the case for how aggressive or specifically how maybe tactically providers should be bringing up myopia with parents.

Matt Erding (12:19)

Yeah. I'll start with the original research from 10 years ago. What we found is parents need to hear about this, but it can't. You can't make them feel too guilty. So parents of school age kids in particular already feel guilty about a lot of. They feel like they're not taking care of their kids needs, mental health, whatever it might be. They worry about their performance in school or sports or other activities. And so when we tested out different messaging, some of it was kind of laying on the guilt of if you don't do this for your child, you're a bad parent. Well, we learned quickly that's not the right approach because parents just shut down at that point. So they need to be seen more as you're educating them and you're a partner and that this is an option that they can and should choose. And you as the eye doctor are recommending for helping their child. And even using language like this is relatively new, so you take away some of that guilt so that parents, you know, who say, well, why haven't I heard about this before? Am I a bad parent? No, you're not a bad parent. You just, you know, this has all been really developed in the last 10 years. Medicine changes and advances are made and parents connect with that, that we're always learning and innovating and doing new things. So you can kind of put them at ease that you're not a bad parent for not having heard about this before. As we know, there's a big genetic component to myopia. So a lot of these parents were myopic themselves. So they remember back to second grade, third grade, getting glasses for the first time and how awful for many of them it was. They got used to it, of course, and they could see clearly. And we've even talked to parents that they had their own retinal issues in their 40s or 50s because of high myopia. So you can kind of connect with those parents as well and say there's something you can do for your child that just wasn't available when you were a child. And that's a great way to talk to parents. And you know, when we started our first two triathlon company centers, I spent a lot of time in those centers talking to parents. So I probably talked to three or four hundred parents of kids in treatment over the years. And what I've learned is they want to be given the option and knowledge that there is something I can do for my child. They may not choose to take advantage of it. Right away. There may be financial constraints, they may want to do their own research, et cetera, but they want to hear about it from their eye doctor first. And we often would hear parents coming into our treehouse center saying they were a little bit upset with their regular eye doctor because they didn't hear about it from them first. So they want to be educated and they want to understand not only the long term benefits, but they want to understand the near term benefits. That's another thing we've learned is if you only talk about you're reducing your child's long term risk of eye disease when they might be 40, 50 or 60, it's not always that compelling. So you also have to talk about we can slow down the progression of their myopia now and they're going to get better vision, it's going to help them in school, sports activities, whatever they may do. If they're in an orthok lens, there's some added benefits. For example that they can be glasses free all day. So there's a lot of near term benefits and being able to talk to parents about those, those are the more tangible ones. You know, I've worked in healthcare for a long time and I remember one of our agencies saying the hardest thing to do in healthcare is get someone to take action now to prevent something that may or may not happen later. Like that's really hard. So I think being able to talk about the near term benefits of the child having more confidence, their vision not getting worse, we've learned is important as well. Yes, you still want to talk about the long term risk, but being able to balance that with what are the benefits my child's going to get now are really important.

Eugene Shotsman (16:11)

That makes perfect sense too because I think I would like to take action now to improve my child's outcomes tomorrow or next week or and like you said, you know, it's going to make school easier for them, it's going to make sports easier for them, it's going to make their day to day activities easier and it's going to long term prevent this bad thing that could happen.

Matt Erding (16:35)

Right.

Eugene Shotsman (16:35)

That's kind of the, that, that, that's the premise. I also liked, I'm just going to restate for our audience. I liked when you said it's a nice way to reduce or to eliminate the guilt to say something is now available that wasn't available before. New cells. Matt. I mean I'm a marketer. I know, right? Like the idea is that always new, better. That kind of stuff is it's a great reason why to take action. So positioning it as both new and state of the art is really great. So this makes sense. And, you know, I guess if I think about it, I. I have a really close friend and I kind of use. Use him as a great example because they switched eye care providers recently. And specifically, the reason they switched is because somebody in some parent group that the dad in this case belonged to said, hey, you should take your daughter to our eye doctor because there's this thing called myopia and this. And these guys do this, these crazy contact lenses that prevent your kid from getting worse. And that was like, that was the thing, Right. And this is also a parent who spends, you know, that every time I talk to him, like, every night his kids are in hockey or in swimming or in skating or something.

Matt Erding (18:01)

Right?

Eugene Shotsman (18:01)

Like, and so lots of, lots of activities for their kid. And, you know, he didn't blink twice to say, oh, this is going to help her. This, of course, like, why not? Right? So how does this line up with other behaviors that parents take to, at least in your parent research? How do parents respond to saying, hey, this is a medical treatment. And how does this line up with other things that parents do that are clearly optional, but they do it for their kids? Right. Like, you know, soccer is not mandatory. But yet we all think that it's good for our kids to have some sort of sports in their lives, right?

Matt Erding (18:40)

Yeah. So what's interesting, when we did that original research ten years ago, we. We talked about the concept of this, we talked about different ways we might treat it. We then asked the parent, what would you expect to pay for something like this? We didn't give them a price point. If we could do this for your child, assume it works. Because there was a lot of skepticism because they'd never heard of this. What would you expect to pay for it? And as humans, and you know this as a marketer, we look for analogs when we have something new that we just have no experience with. And so their parents, 16 parents, they either went to Lasik because some of the parents had been myopic and had Lasik themselves. So they're like, oh, maybe, you know, $3,000. Or they went to orthodontic braces, which most of their kids had. So they were thinking five, six thousand dollars. I remember one parent even said, ten thousand. And Dr. Gerber, if you know him, looked at me and said, we're charging 10,000. I said, no, we're not. That's one parent. But what was interesting is they were trying to figure out what is something comparable that I invest in already for my child or myself. And what we've done through. We've done additional research since then, is the great analog for parents is orthodontic braces. The age range is roughly similar. The price point for orthodontic braces nationally in the US is actually $5,500. On average, 30% of American kids get orthodontic braces. It's a $30 billion category. It's huge. Wow. And it's an analog parent skit. So there's two things, though, about orthodontic braces that are different that I think it's important to the audience to understand. It's good to bring up, but there's two major differences. One is, in orthodontic braces, you have a visible change at the end. A kid's teeth are straight that you just don't get with myopia. But that's why we really recommend. It's important to measure axial length, because you can then visually show a parent, hey, your child's axial length was doing this and it's flattened out, right? It was going up and it's flattened out, hopefully, or slowed down dramatically.

Eugene Shotsman (20:58)

Well, it's almost like braces before the teeth get crooked.

Matt Erding (21:02)

Exactly, exactly. So that's just one. One difference is there's not a visible thing, but you can make it meaningful for a parent if you're tracking exit length and plotting and showing them that data. The second difference is, and this is a really important one, parents expect to pay for orthodontic braces. It's not new news. So probably when their kid was 7 or 8 years old at the dentist, the dentist probably teed them up and said, I know they did with my kids. Said, ah, your kid's probably going to need braces in a couple years. And so mentally, I was already prepared that the time's gonna come. And, you know, we even saved some money to be prepared for orthodontic braces when the time came. The difference here is often the parent's bringing their kid in for an eye exam. They're expecting to have VSP or something else pay for most of it. Maybe I need an updated pair of frames. And suddenly you're telling them, actually, I'm recommending myopia treatment for your child. Here's why. And the cost is going to be X, and they're just not expecting it. So that's where that analog does fall down a little bit. So being able to talk about price Talk about it the right way. Talk about it as an investment in your child is a little different than orthodontic braces. But, but when you know how to talk to a parent the right way about it and present it, you know, our close rate is over 80%. But in the early days of trial size and our first clinics, our close rate was, was in the 20s. But we've learned over time. How do you talk about this in the right way?

Eugene Shotsman (22:41)

And I suspect that that's a big part of that initial statistic that you shared in kind of the state of, the state of the category. The 78% of optometrists say they're doing myopia management, but only 4 to 5% of the eligible kids are getting the treatment. And you know, you, how big of a billion dollar industry did you say braces are?

Matt Erding (23:04)

30 billion in the US okay, so.

Eugene Shotsman (23:07)

30 billion in the US I was just doing a little bit of math and I was thinking, okay, so you said there's 30 million kids that are potentially eligible candidates. And if you take, I don't know, a quarter of those kids, which works out to what, 77.5 million kids, right? And you take a quarter of those kids, 7.5 million, you say, hey, how much does an average myopia treatment cost? Two grand, right? Something like that.

Matt Erding (23:39)

Yeah, two to three grand for best practices.

Eugene Shotsman (23:42)

So that's $15 billion in revenue. That and I, and I went conservative. I think one out of four kids who are candidates, if you had a really good, like, you know, you said that braces adoption rate is 30, it's 30% of kids. But that's probably, I don't know what percent of candidates, probably a much higher percent than 30% of candidates. So yes, I, I think about this and like that's $15 billion that were, as an industry, we're leaving on the table every year.

Matt Erding (24:14)

No, that's absolutely right. I was asked to do a category overview about four years ago for the Ophthalmology Innovation Summit. Just stated the category and what the opportunity was. And I shared. The total addressable market, in our opinion is about 50 billion. And that's not the entire, that's just the addressable market. So if we treated every kid, it's much higher than that. But yeah, it should be probably a $50 billion category anyway.

Eugene Shotsman (24:42)

So if in, you know, I think you guys have learned a lot from your network and you already mentioned, you know, you have like 80% close rate on treatment or treatment adoption rate, what do you think the average optometrist has as far as their or before people come to you in your network, what does it go from and what does it go to?

Matt Erding (25:06)

Yeah, I've heard various stats from some of the manufacturers. 30, 40% close rate seems to be pretty common for practice. That what we call dabblers. So they're not talking to every kid about it, but they see certain opportunities, maybe a kid that's at high risk and they bring it up before that kid. And one of the challenges with that, if you're not presenting this every week, it's just not second nature for you. So you don't get good at it necessarily if you're only taking a few shots on goal every month, it can be something that's just hard to refine your skill and get particularly good at.

Eugene Shotsman (25:43)

And you're probably overthinking it, you're probably overselling it. I've heard from super experienced providers actually on this show, one of your doctors, Tanmay was saying like, simpler is better, shorter is better. Is that what you guys have learned?

Matt Erding (26:00)

It is. And one thing we've learned, and at some point in like year three, we were on version 23 of our case presentation. So literally Dr. Gerber would go to our clinics and videotape patient interactions from the od, which they hated of course, and then analyze it afterwards and look at, oh, here's where you lost them, you said this. And I think the most common mistake we've seen is optometrists getting into the weeds of the technology too much instead of keeping it simpler and focusing on the benefits. Because benefits for most parents is what they want to hear about and understand. Do they care about your 11 concentric rings or the exact number of microns you're reshaping the cornea? No, but optometrists are scientists that well clinically trained and a lot of times that can be their go to. Well, let me tell you about how it works. And there are a handful of parents that will ask about that and want to know that. We call those the technical buyers.

Eugene Shotsman (27:03)

But the technical buyers are about 15% of the population. The 85% population are non technical buyers.

Matt Erding (27:10)

That's probably exactly right. You know the stats better than I do. But our experience is you focus on the benefits. Not necessarily. So I again, I go back to a good analog with the orthodontist. When both of my daughters needed orthodontia treatment, he didn't come in and say, I'm going to put in 32 brackets, I'm going to put in 12 rubber bands and I'm going to do this, that and we're going to move it by so many microns a month. He just said your daughter's a good candidate. The treatment's probably going to be about two years. It's going to cost $6,000 and she'll tell you how to pay and we'll have your kids teeth straight. And that was it. And I'm not saying it always should be that simple for myopia management, but Dr. Ma, who's one of the best in the country at this is right. So simpler's better, focus on benefits, not necessarily the, the detailed science unless they want to know and then you can be prepared to talk about that. Yeah.

Eugene Shotsman (28:09)

Do you find that there's the right amount of time like for a, for somebody who is practicing, who's working that muscle every single day when they're seeing kids. What's the, how long does it take em to do a rep if we're gonna stay with the same analogy?

Matt Erding (28:28)

Yeah. When we first started we allotted 45 minutes for a discussion with the parent on education, case presentation, et cetera. We were able to get that down to more like 15 now through better words, shorter case presentation. And then we have some tools that we use to pre educate parents before they come in, some video content. We now have a tech doing some of the pre workup so that by the time they get with the OD they can do the clinical portion of the exam, make the recommendation, maybe answer a few questions. It might take an extra five to 10 minutes that you wouldn't normally account for in an eye exam.

Eugene Shotsman (29:12)

Got it, Got it. That makes sense.

Matt Erding (29:14)

But I will tell you even that five to 10 minutes, if you're in a primary care practice and you're running behind and maybe you only have 20 minute slots, it can be tough. And that's why we often tell practices if you leave it to just the optometrists to implement myopia management, it's not going to be successful. It needs to be a whole team approach. How can your staff help with that process? How can even the optical staff who's helping with frame selection and things like that afterwards reinforce the recommendation so it doesn't all have to sit with the optometrist.

Eugene Shotsman (29:46)

Does it make sense to. If you're saying it's hey, it could potentially be a 15 minute appointment, do you potentially bring them back or do you find it's more that you have a higher success rate if you just hit it during the comprehensive exam?

Matt Erding (30:02)

So what we recommend we Have a model where we partner with full scope optometrists to implement myopia management in their practice. And what we recommend for them because they are doing primary care eye exams is at the end of that eye examination, it's about a one to 90 second max presentation. We call it a mini consult. And essentially it's saying your child has myopia. It's progressing, it's going to keep progressing. I'm recommending treatment for them. I want you to come back. We're going to do a dedicated consult. I want to do a couple additional tests and we're going to talk about treatment. So we find it better if you try to cram it into, in a comprehensive eye exam, it's really tough. But taking, teeing them up throughout the process, starting with the staff and then taking that one to one and a half minutes. Most parents will say, okay, I'll come back. It's a free consultation. You might even be able to tie it into if they're getting new glasses or contacts when you come pick those up, we're going to do it then so you can save the parents some time as well. So we do find it better if, if you're doing a comprehensive eye exam, bring it up then and maybe bring them back for a dedicated myopia consult.

Eugene Shotsman (31:17)

Got it. And some practices probably charge money for that. For some practices it's free.

Matt Erding (31:23)

Yeah, yeah, we tried it both ways. For our practices we, we do it free just because we will. We want to reduce the barrier to the parent. Some practices like to charge for that and then they might apply it to treatment, for example, if the kid moves forward in treatment.

Eugene Shotsman (31:39)

Well, and with an 80% close rate, you can absolutely afford to do that for free. If you've got, you can, if you've got what's an average treatment?

Matt Erding (31:48)

2 to $3,000 for most practices. That's what they're charging. Maybe for the first year. Practices have different models. Some charge the same fee every year. We tend to charge a higher one or two year fee because that first year or two is when a lot of the more intensive work is being done. We're bringing them back a little more frequently. We want to measure axial length if we need to change treatment because the doctor's not happy with the results they're seeing and then we charge a lower fee in the outer years.

Eugene Shotsman (32:19)

Got it. Makes sense. But 80% is still, I mean, I think you can afford to spend a little bit of money on the consult and time and money on the consult. If you're closing 80% for an optometrist who's closing 30%. They probably can't do that for free, which then again creates another barrier, which then creates another reason why their patients don't get the treatment that they potentially are candidate for.

Matt Erding (32:44)

That's absolutely right. What we find with a lot of practices is they've presented this to 5, 10 parents. Their close rate maybe was 30%. They got 7 nos, 3 yeses, and that can be a little daunting. You lose confidence, you say, I'm not sure people will really invest in this. And probably the right answer is you're not presenting it in the right way most of the time.

Eugene Shotsman (33:09)

Yep, that makes perfect sense. And you're. And doctors don't like to sell anyway. And so I'm doing something uncomfortable and then I'm getting a no at the end of it. Well, I'm just not that good at it. I'm just going to do the stuff that's really comfortable for me.

Matt Erding (33:23)

Right. And the other thing, and it's not research, but just our experience in our centers, is because this is oftentimes the first time a parent maybe has heard about this, a lot of them say, I need to talk to my partner about this. We get that a lot. And if only one parent's in the appointment, which is usually the case, it's a big financial investment. In my own marriage, we have a rule that if anything's more than $500, we have to talk about it first. So if you're being presented with a price tag and an investment you didn't expect, it's perfectly natural to say, hey, I need to talk about this and get back to you. And this is where again, a lot of practices they don't follow up at that point and they assume that the parents are not interested. But the reality is parents of school age kids are busy. So how are we teeing up? If it was mom that brought the kid in and needs to go talk to her partner, are we giving her the right information to go share? Are we following up to make it easy for, for that discussion to happen at home? And we've actually found you need to follow up five times. Five's the magic number. And that can be an email or a call. And a lot of times staff say, well, I already called them once and they didn't answer, or they didn't return my voicemail, or I emailed them and they didn't get back to me. You've got to keep that follow up. Because a lot of times we see on the fifth outreach is when parents say, oh, yeah, I finally had time to talk about it. Yeah, we're get us booked to like, we're going to start treatment.

Eugene Shotsman (34:58)

Yeah. What about bringing both parents back for that, for, for that dedicated myopia consult?

Matt Erding (35:08)

It's ideal. But I'll tell you, and I know some practices that it's almost mandatory for them. It's really hard. I think you're putting a burden on the family. I know if you, if the doctor said that to my family, I need both parents there. Well, that might not happen for three months. And just because of schedules. Right. Both parents might be working. You're shoveling kids to school and activities. So I don't think it's mandatory. I think what's better is you have some tools that tee up the parent to talk to the other parent. Or like we have. We call it triass amp, our automated marketing platform. It's video content. You know, we can send that directly to the partner that they can get a little better educated themselves.

Eugene Shotsman (35:50)

That makes perfect sense. Okay, when we come back from the break, I want to talk more about some of the other parent research. I know you guys did some additional parent research recently, specifically around some of the new treatment modalities. We'll be right back in the power hour. And we're back in the power hour. I'm here with Matt Erting, and we are talking myopia from kind of all different angles of the industry. So I think I want to go back to a little bit more parent research. You guys have really recently done some parent research. So attitudes towards myopia and then also attitudes towards treatment modalities, Right?

Matt Erding (36:26)

Yeah. We last summer realized that myopia glasses were coming. So we've been talking to all the major players for the last few years. Asolor, L. Exotica, Hoya Cyclass. And we knew they were coming and we weren't sure. A tria size. How do we position these to parents? Because glasses is a whole different treatment modality. I had gone to Australia a couple years ago and spoke to a lot of doctors over there, talked to Canadian docs, talked to Chinese practitioners that have had glasses for several years. And I just thought it was important that we do some research with parents to think about when these are available, how do we talk about them and what questions are we likely to get that we want to make sure our staff is ready to answer. So we did two different cohorts of parent research last summer. One was with parents of myopic kids who were in treatment the other was parents of myopic kids who were not in treatment. Because we really wanted to understand the difference between those two. And we really got some surprising, I think, findings and insights that have helped shape now that Stellist is actually available here in the US that we're rolling out to all of our trail size providers to make sure we feel like they are armed with how to talk about this, not just the technology side, which Esselor is going to do, but just from a parent perspective. How do we bring these up when we think this is going to be the right treatment modality for their child?

Eugene Shotsman (37:56)

So what are some of the things you learned that you're comfortable sharing?

Matt Erding (38:00)

Yeah, I'll say. Overall, the one interesting thing that we didn't really expect is that there was more skepticism from parents that glasses can treat myopia. And the reason was, and we had more than one parent say this, they said, well, how can this work if it doesn't touch the eye? And that just being in the category and industry for a long time, I'm like, well, of course it can work, right? It's an optical intervention and glasses can do that. But to a layperson, they understood that a contact lens or even atropine, those touch the eye. So therefore they can have some physical effect on how the eye grows. But glasses don't. So how can that work? And so that's really helped guide us a little bit in how we talk about these. You do need to, while you want to focus on the benefit, you do need to talk about these are special glasses that are FDA approved specifically for this. And you can talk just maybe briefly about it's an optical intervention. And what it does and what we've done and we're training all of our doctors is you can say it's just like the contact lens options, they work mechanically in the same way. It's just delivering it in a different way. So that was just a really surprising thing that we found. One thing that we found from that research, I think the other thing we found is parents who had kids in treatment already, in some cases for several years maybe all wished that glasses had been available when their kid was young, so that that might have been an option because it just wasn't back then. And so we, we started a lot of our kids at age 6, 7, 8 in, in treatment. You know, we want to intervene early and for some kids, contact lenses might be a bit of a struggle now. We got them through it through a lot of hand holding and, and good care, but a lot of them said, oh, I wish that had been available, maybe, maybe it would have been training wheels for the first year or two, you know, for my child. So I think the fact that Stellist in particular has approval as low as age 6 is really going to expand the market opportunity to get some of those younger kids who, you know, just aren't ready or the parents are, don't think they're ready for a contact lens option or just for whatever reason, even they think atropine is not something that they want to do for their child.

Eugene Shotsman (40:23)

Do you think? And I guess, you know, if you kind of compare and contrast some of the different treatment modalities, how do glasses in general, stellast or otherwise, how do they stack up? And what have we learned from other countries too?

Matt Erding (40:39)

Yeah, I'll start with just the data that's available from their FDA approval. So efficacy in their trials over the first two years was great. So it's very comparable to what we've seen in misite studies or natural abuse protect study or some of the ortho case studies. So that's a good thing. The concern that I've heard from practitioners in other countries that have had any glasses options for a few years is compliance. So in a clinical study setting, kids are wearing these lenses, these glasses for 10 to 12 hours, six days a week minimum. The question is, are we seeing that in real life? And the answer is it's mixed is what I'm hearing from practitioners in other countries. So I think patient selection is going to be really important that you're confident as the practitioner that they're going to be compliant because if they're not wearing the glasses. So let's say the kids are minus 125. You prescribe a myopia glasses for them, they got to wear them 10, 12 hours a day, six days a week. Are they really wearing them all day at school? They can see okay without their glasses. Do they take them off for activities? Did they just take them off because they get uncomfortable for some period? So I think patient selection is going to be really important. And then I think the other key thing is you can't just prescribe these and forget about the aftercare piece of things. So you're going to want to bring that patient in every three to six months is what we're recommending. Do Axiom length check, et cetera, because self reported they may not tell you if they're being compliant and the parent may not even know. Again, we don't see our kids all day at school, so we don't know for sure if they're being compliant. So monitoring them and monitoring not just the refractory, but axial length to see is it working? And then making an adjustment to the treatment plan if needed is going to be really important with glasses.

Eugene Shotsman (42:36)

Yeah. And I think, you know, you bring up a good point, which is that, you know, the, the difficulty, the challenges of contact lenses are something that you don't encounter with the glasses. But at the same time, the challenges of glasses is something that you're also trying to, you know, you're trying to sell the fact when, during the, during the case presentation. Right. To the parent. You're trying to basically sell to the parent that, you know, you're trying to slow them about progression of myopia. And in the parent's mind, I'm sure sometimes like, oh, this is gonna not have to, My kid's not gonna have to wear glasses if they're doing this treatment.

Matt Erding (43:16)

Right.

Eugene Shotsman (43:17)

And that, and there's all kinds of negative things associated with wearing glasses for kids.

Matt Erding (43:23)

Right.

Eugene Shotsman (43:23)

From the, how do I, you know, self image things, but also like the practical things of like, it's just harder to run around and be a kid if you're wearing glasses.

Matt Erding (43:35)

It is. And we know kids break their glasses a lot. So what happens when they break their glasses and it takes two weeks to get new ones? Well, they're off treatment for that entire time. So one of the things we're considering for our practices is once you make sure they've adapted, which is about a one week period according to Slor, at least for Stellus. Do you just dispense two. Right. Is that part of the package? So they always get a backup. And so just considerations like that I think are really important. I think the other thing with glasses is, and we learned some of this in our research as well, is you don't today, I think most optometrists, the eye exam and the medical piece is one thing and then the optical is another. So you go from I'm a patient to I'm a customer shopping for nice frames, etc. You can't do that with these myopia control glasses. This is a medical treatment. It's a Class 2 FDA device. So you don't want to separate the glasses from the medical exam piece of things. So I think that has impact in terms of how you think about pricing. You know, just saying, okay, yeah, I've got my eye exam and I'm done. And now you go out to the optical and, you know, get your frames that work with stellus. And that's a separate charge.

Eugene Shotsman (44:58)

Yeah.

Matt Erding (44:59)

It might be billed separately and managed vision carriers are going to have some allowances and things like that. But bundling it all into this is a medical procedure that we're doing. Glasses are just a tool I'm using, just like I might use atropine or a contact lens option is going to be really important because otherwise, I think you devalue the optometrist skill and the medical treatment portion of this. And from a parent's perspective, well, it's just glasses, so, like, what's the big deal? So I think that's going to be something we have to navigate. And optometrists have to think about how they position these. And you don't want it to just be treated like another pair of glasses. Yeah.

Eugene Shotsman (45:35)

And I think, you know, it's interesting as I'm thinking about how most optometrists price their myopia program, which is usually there's a price and that's it. And, like, stuff is included. And I'm curious whether. Now we have to start thinking about, okay, this is how many remakes you get. Right. How many times is your kid allowed to break the glasses? And what if the lenses are scratched when those glasses are broken, then, you know, what do we do then? And glasses are easy to lose sometimes if you do take them off during the day. So I think about how that impacts an optometrist who's trying to bring this new modality into their practice in general.

Matt Erding (46:23)

Yeah. And I think what we're going to see is those practices. And again, based on the numbers, there aren't tons of them that really drive myopia management. It'll be just another tool in their arsenal. And whether they choose to dispense two pair up front or one, it's going to be pretty straightforward. I think, for practices that haven't done much myopia management or just dabbled in it, getting their head around, what are my policies on this and how does it need to be different than normal glasses? Thinking about my professional fee and how I charge for that. So it's not just seen as well, you get an eye exam and BSP is covering that, and you get a managed vision care allowance for this and then that's it. Right. Because you do need to see that patient back frequently to check refractive air and axial length. And you want to, you know, optometrists should be paid and reimbursed appropriately for their professional time for that. So I think, I think glasses will expand the market that's certainly our belief is more optometrists that maybe weren't comfortable with ortho K or just never really got into soft lenses and maybe weren't comfortable with atropine. The great news is we have another option that maybe feels more familiar and more comfortable. But I think also thinking about just making sure it's not seen as just another pair of glasses, it's going to be cool.

Eugene Shotsman (47:50)

Yeah, I think that makes sense. And you know, from a cost of goods standpoint, I know that there are some optometrists who approach myopic management from a, you know, cost of goods times three type of thing. And, and then they charge maybe separately for their professional time. Or there's other ones who say, hey, there's, you know, this is a flat fee program and here's, you know, call it $2,000. And this is, and it includes any of the modalities. I guess if you consider all the modalities. What, what is the most, what is the most advantageous from a cost of goods standpoint? But then it may also be time consuming. So you have to balance that specifically.

Matt Erding (48:32)

Yeah, and, and you've got it exactly right. So if you just look at the cost of goods, most of the time an ortho K lens or pair of lenses is going to be your lowest cost of goods versus an atropine. A soft lens or, or potentially glasses will probably be in the same realm as, as an ortho K lens. Ortho K requires more time and more expertise so that kind of can balance that out versus maybe a soft lens. So I've seen two models and I think both are valid. One is we're going to keep it simple. It's a global fee and we just, we're working to reduce your kids myopia progression. Kind of like the orthodontic model. The other model, again equally valid, is I'm going to kind of charge atropines easier. I don't need as much maybe professional skills. So I might not charge as much for an atropine regimen versus ortho.

Eugene Shotsman (49:28)

Okay.

Matt Erding (49:28)

I'm going to charge more for especially a complicated fit that may be harder. So I think you can, you can choose whatever you feel is right for you for your practice. For me, it's, it's about helping the kids. So however you want to charge for it as long as you feel comfortable with that. And you also know how to talk to a parent about why the fees are what they are.

Eugene Shotsman (49:47)

Yeah. So Matt, before we wrap up, I'm Going to kind of ask you to list. And we've maybe covered some of them on the show already. But if you had to kind of list the biggest mistakes that people make, I just want to reiterate some of these again. And, you know, I'm all about helping the industry close this gap that you identified in the first few seconds of this. Of this episode, when we Talked about the 78% of optometrists say they're doing something with myopia management, and yet only 3 to 4% of the kids who are candidates are in treatment. And so in order to close this gap, let's itemize the top three mistakes that we really need to stop making. And really, maybe at the same time, we can talk about how to take action and stop making those mistakes.

Matt Erding (50:49)

Yeah, I think number one is not recommending treatment for every child who would benefit. That's just the number one mistake. We're not bringing it up consistently in every practice, and that's being driven by. It's sitting with the OD only and the staff's not involved. Lack of confidence from the optometrist, or oftentimes they're judging the pocketbook of their patient, saying, I don't know if they could afford this. So, number one thing, practitioners, is talk about it. Yeah.

Eugene Shotsman (51:22)

And I think I'll add one more to that, which is inconsistency between doctors is what I've seen. You know, one OD is doing great. Oftentimes the owner od, and then, you know, the two associates who are in the practice are barely bringing it up. And I think you make a really good point, is that if they're a candidate, just bring it up. And you, even during the show, you gave a quick, you know, you call it your micro consult or whatever, your mini consult, if it's an extra 60 seconds, that has a chance to make a big impact in that person's life and also have a meaningful economic impact on the practice. Why not? Right. Why not make that investment?

Matt Erding (52:04)

Yeah, I agree. That's number one. Number two is it's related, but it is different. Bring it up before they're myopic. So it sounds a bit weird, but go back to the example we talked about earlier in the show. Our dentist started telling us when our kids were 7 or 8, your child's likely to need braces. When they were 11 or 12 and needed braces, I was prepared for that. Mentally, emotionally, and financially, I was prepared for that. So oftentimes a kid's first experience with an eye doctor might be age 6, they're going to school for the first time. Not many kids, more kids now are myopic at age 6, but a lot aren't at that point in time. Even if they have no risks, even if the clinical exam shows they're probably low risk for developing myopia. Bring it up at that point in time. Right. I'm measuring your child's axial length. We're going to track it every time they come back. Here's why. There's this thing called myopia. And it progresses and we want to catch it early. So if that child at age nine is suddenly at minus 75, their axial length is popped to 23 and a half. It's not a surprise to the parents. So that would be my second thing is don't just bring it up when you see the kid's a candidate now. Bring it up.

Eugene Shotsman (53:30)

Have the conversation a couple times before they're a candidate.

Matt Erding (53:34)

Yeah, absolutely.

Eugene Shotsman (53:35)

Makes perfect sense.

Matt Erding (53:36)

And then from a, from a practice perspective, the third thing I would say is follow up. When you make a recommendation for treatment and they say, I got to think about it, which a lot of them are going to do. Follow up, follow up, follow up. It can be hard for your staff. This is a service we provide our Triassis providers. We follow up on their behalf for them. But just have someone designate in the office that rule of five. Follow up five times. Right. Once a week for five weeks until, unless they say no, stop bugging me, or unless they say yes, and then put a note to follow up again in three months.

Eugene Shotsman (54:14)

And the thing I like about your program is that they're not just following up and saying, hey, you know, just check in to see if you're interested in treatment. They're sending valuable content, they're sending valuable information that continues to, that continues to position the practice as an expert and continues that kind of stream of education for the parent. So the parents like, yes, I was exposed to something new. I do have to make this decision. Oh, and here's another reason why I should make this decision.

Matt Erding (54:41)

Right.

Eugene Shotsman (54:42)

And I think that there's a difference between annoying follow up, which is why I imagine most people don't do it, and value add follow up, which is kind of an extension of care.

Matt Erding (54:53)

Yeah. And I think it's also just not assuming the parent isn't responding to you because they've decided. No. It's just recognizing parents are really busy. Oftentimes I'm getting back to my child's healthcare provider at 9 at night on email or online through the portal. So we're busy. And that constant follow up gives us that opportunity to remind us and hopefully have that conversation that we need to have at home before we're ready to commit to truth.

Eugene Shotsman (55:20)

So those are great. Top three. I'll put them in the intro of the show too. Thank you so much for joining us today on the Power Hour. I think you've got a wealth of knowledge and so much information. We'll make sure to post information about how people can reach out to you in the show notes. And just pleasure having you on the Power Hour today.

Matt Erding (55:39)

No, I appreciate it, Eugene. This is a topic that's near and dear to my heart and we just want to help those kids that deserve that opportunity to be helped. So I appreciate the opportunity.

Eugene Shotsman (55:50)

And there's a lot of kids who are not yet in treatment, so hopefully we'll change that over the next few years.